How I Treat: A 67-Year-Old Woman With Asymptomatic Carotid Disease

Michael J. Bloch, MD

Introduction. A 67-year-old woman presents for follow-up of dyslipidemia and is found to have a carotid bruit.

Patient history. The patient is a former smoker with a 22 pack-year history. She has known hypertension and dyslipidemia, but there is no known history of diabetes. She does not have a history of previous heart or vascular disease, nor any known history of previous stroke.

There are no indications of symptoms consistent with stroke or transient ischemic attack. Additionally, the patient has no angina, shortness of breath, nor any other cardiovascular complaints. Her current medications include valsartan HCT 320/25 mg daily and atorvastatin 10 mg daily. Regarding notable family history, her father had coronary artery bypass grafting at 67 years of age.

Physical Examination. The patient’s blood pressure is 128/78 mmHg, and her heart rate is 78 beats per minute. She is afebrile with oxygen saturation of 98% on room air. A right-sided carotid bruit can be heard with a stethoscope. Lungs are clear to auscultation with no wheezes, rhonchi, or crackles.

On cardiac examination, there are normal heart sounds without murmurs, rubs, or gallops. The abdomen is soft and non-tender without pulsatile mass. There is no clubbing, cyanosis, nor edema in the extremities. Dorsalis pedis and posterior tibial pulses are normal in both feet. There is no pronator drift, and all cranial nerves are intact. The patient has a normal gait and no dysdiadokinesis.

Her laboratory work is notable for renal function and blood counts that are within normal ranges. The patient’s low-density lipoprotein cholesterol (LDL-C) is 102 mg/dl with high-density lipoprotein cholesterol of 42 mg/dl and triglycerides of 158 mg/dl. Her blood glucose is 105 mg/dl and glomerular filtration rate > 60 mg/ml/min. Carotid ultrasound demonstrates a >70% right internal carotid stenosis and a 50% to 70% left internal carotid stenosis

Treatment and management. Computed tomographic (CT) angiography confirms an approximately 80% right internal carotid stenosis. After shared decision-making, the patient is referred to a vascular surgeon who performs a right carotid endarterectomy (CEA) based on the Society for Vascular Surgery (SVS) recommendation to perform elective CEA (over best medical therapy alone) in low-risk surgical patients with asymptomatic carotid stenosis 70% to 99%.¹ (Level of recommendation: grade 1 [strong]; quality of evidence: B[(moderate]).

The patient spends one night in the hospital and is discharged the next day after confirming that her blood pressure is well controlled, and there are no signs of neurological deficits.

Patient follow-up. A CT carotid duplex performed 3 months after the procedure shows no evidence of restenosis or intimal hyperplasia and stable contralateral disease.

The patient’s blood pressure remains < 130/80 mmHg at home. She continues with the same blood pressure medications. Per American College of Cardiology/American Heart Association guidelines, she is changed to atorvastatin 80 mg daily with a goal LDL-C of < 70 mg/dl.² Aspirin 81 mg daily is started to reduce the high risk of heart attack and stroke associated with carotid atherosclerosis. She will obtain a repeat carotid ultrasound in 1 year and will need lifelong surveillance to make sure that he does not develop restenosis or worsening contralateral stenosis.